MD HAS QUESTIONS ABOUT GASTROC PERFORATOR

Last Updated: 11/10/2010

November 10, 2010- Dr. Bush responds to Dr. Mueller

No problem with extravasation with foam. You must remember that the venous circuit is extremely low pressure and that phlebectomy followed by compression would be safe with or without foam sclerotherapy. Foam sclerotherapy of the perforator will help to prevent reoccurrence. As an alternative, you could use foam alone to treat both perforator and varix. You would be left with a clot that would take time to resolve and cosmetically could take 6-8 months to achieve that obtained by doing phlebectomy.

We use a 22-gauge needle and a 3-cc syringe for these percutaneous cannulizations of the deeper vessels.  I use a small amount of tumescent solution for the skin. With US guidance, I cannulate the perforator, aspirating dark venous blood. Steady the needle with a hemostat after cannulating the vein. Exchange your syringe for one filled with foam and slowly inject the foam using a slight pumping action. After the foam is in the perforator, I inject tumescent solution around the perforator to help constrict the vessel.

I think this technique to some degree is explained in Courses 1, 2a, & 2b of the Bush Venous Lectures.

Hope this helps

 

Ron

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November 10, 2010- Dr. Mueller has more questions about treatment

Last question on this case, ron, much appreciated: do you still think i should close the perforator even though i couldnt demonstrate reflux in it? seems like it should be the culprit for the varix though perhaps its an innocent bystander...no concern about sclerosant extravasation after disarticulating the varix and/or perforator? thanks again for the great and instant advice, rich

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thanks peggy and thanks ron ! will try to foam the perf as it exits fascia but thats right at the very top of the perforator and just under the skin, where the varix makes 90 degree turn and runs under the skin. hopefully will be covered as i couldnt prove pw doppler reflux in the perforator but common sense shows its related to the varix that emerges from it...

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November 10, 2010 – Dr. Bush responds to Dr. Mueller

1.    Veins don’t bleed so don’t worry about avulsion.

2.    As an alternative, use a 25 butterfly, inject directlyinto the variex with 0.5% sotradecol foam. Milk it inferiorly. This should close the perforator then do your phlebectomy.

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November 10, 2010- Dr. Mueller has more questions for Dr. Bush

Thanks for the instant reply, ron. main initial concern was avulsing a deep vein and getting into uncontrollable bleeding but our local chief of vasc. surgery says that very unlikely. i might stop his aspirin though (though he has old svt and could be hypercoagulable...). would you advise butterfly or 21g micro introducer sheath access of perforator to prevent injection into accompanying perforator artery? or just needle under u.s. guidance sufficient? angiocaths bore is just too large. perf. is 4 mm but no reflux on pw doppler interestingly. would you still sclerose it? and i see no concern about the fact that the perforator is all subfascial...thats a relief. purpose of perf. sclerotherapy rather than just routine a.p. of the varix is to prevent new varices by ablating the perforator, i presume? the perforator may just get pulled out at the time of the ap anyway, which raises the theoretic of extravasation of foam then into the subfascial muscle...thanks again ron !

 

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November 11, 2010 – Dr. Bush responds to Dr. Mueller

By definition there must be a communication between the perforator and the superficial varice. Foam the perforator as it exits the fascia. I would not use liquid because it is not as effective.

 Ron 

Dr. Mueller, just wanted to let you know we will be in NYC on December 11, 2010 for a VeinGogh workshop. The information is listed on the blog under topic ‘VeinGogh’ on left or you can visit www.veingogh.com

Peggy Bush, APN

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November 11, 2010 – Dr. Mueller has more questions

Dr. Bush,

Just submitted by own gastroc perforator case and then noted this posting you shared. our gastroc perforator is completely subfascial. any concerns about u.s. guided sclero if its all intramuscular. i know you have correctly pointed out that all sclero foam or liquid eventually goes into the deep system but this perforator is all deep in my patients case... would you use foam or liquid? many thanks again. i didnt post my clinic info last time:

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November 10, 2010 - Dr. Bush responds to Dr. Mueller

This case is probably very similar to the one listed on our blog ‘GASTROCNEMIUS PERFORATOR VEIN.’ These cases are simply handled by doing subfascial injection of the perforators using 1% sotradecol foam with phlebectomy of the visible varix. There is no need to do any type of ligation whatsoever. Many patients with venous disease also have incompetent gastroc perforators so this is not an unusual finding. Do not be afraid to use US guided foam sclerotherapy as the risk of DVT is almost nonexistent if done properly. 

Ron

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November 10, 2010- Dr. Mueller has questions about treating a gastroc perforator

I’m a boarded phlebologist / cardiologist (non surgeon).  I have a pt. whose varicosities and symptoms have cleared 90% after evlt of gsv and one round of a.p. however, one large calf varix remained and he wants it out. on doppler it comes off a perforator (entirely subfascial in course) leading to a deep vein tributary that dumps into a very large gastroc venous sinusoid. about 2.5 cm of superficial varix under the skin before dives into the perforator. cant ablate perforator with sclero or laser as its all subfascial. my concern is the theoretical risk of avulsing a deep gastroc. but since ap of perforators is an accepted treatment there is always a theoretic risk of tearing a deep vein. however, this perf is all subfascial. several surgeons have advised u.s guided a.p. with a proximal ligation with one loop of 3-0 silk. as a non surgeon, are dr. bush and fellow phlebologists comfortable with my doing this. dont want to stray from scope of practice but tying one suture proximal to a hemostat after exteriorizing the vein seems simple enough and pt prefers i do it rather than a vasc. surgeon. i even have one of my trusted dermatologists nice enough to come to the procedure and watch me do it and bless the knot ! would appreciate everyones thoughts, i want to provide best treatment but not go beyond my bounds. perhaps i am overanalyzing what probably happens without our knowledge on blind ap's all the time.... many thanks !